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A book recommendation

This is a lot of information to get to a book recommendation at the end, but I hope the information along the way will be helpful.

In occupational therapy, context refers to a variety of interrelated conditions including cultural, physical, social, personal, spiritual, temporal, and virtual factors that influence performance (AOTA, 2002). Performance contexts are taken into consideration when determining function and dysfunction within an environment.

The concept of “contextual factors” was not explicitly stated in the occupational therapy literature until the profession adopted Uniform Terminology III (AOTA, 1994). This document included the earliest named references to contextual factors that occupational therapists consider. Specifically, it mentioned temporal aspects including chronological age, developmental stage of maturation, point of location in the life cycle, and disability status. Additionally, the definition of cultural contexts includes customs, beliefs, and activity patterns; although these contexts may be culturally transmitted they are personally acted on and could be classified under a broader scheme of personal contextual factors. Although other authors discussed these factors, prior to this time there was no cohesive set of principles that outlined occupational therapy’s domain of concern regarding context.

Winnie Dunn was Chairperson of the taskforce that developed UT-III and at the same time she was developing her Ecology of Human Performance model (Dunn, Brown, & McGuigan, 1994). This model was designed with the purpose of accounting for the influence of the environment on human performance because Dunn believed that there was a lack of consideration for complexities of context in occupational therapy. Under the assumption that “occupational therapy is most effective when it is imbedded in real life,” temporal and environmental contextual factors are identified that allow practitioners to interpret behavior and choose appropriate and meaningful therapeutic interventions. She stated that ecology (the interaction between person and environment) affects human behavior and performance, and that this performance can’t be understood outside of context. Most importantly, she stated that contextual factors include physical, social, and cultural elements, and are considered to be broader than environment as they also include the experiences of the person. Dunn’s specific statement about the individual’s phenomenological perspective on their own situation was germane to the AOTA’s uniform terminology document, and had a broad impact on how future occupational therapy theorists incorporated contextual factors.

Although I have outlined this before, I will repeat it here as it is ‘contextually appropriate’ to do so: some recent practice models explicitly identify the relationship between the individual, the occupation being performed, and the environment. The P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) explicitly states that the behavior can’t be separated from its contextual influences. Additionally, this model re-introduced the importance of history-taking for establishing personal contextual relevance for goal setting. Similarly, the Lifestyle Performance Model (Velde & Fidler, 2002) takes a congruent approach by completely embracing phenomenology as being the only possible method for understanding the personal contextual relationships between an individual and the occupations that they engage in.

How has the profession operationalized contextual concepts? Occupational therapists generally intervene at the level of the individual, although there is some growing discussion about population-based interventions (Scaffa, 2001). Still, for occupational therapists, contextual study generally doesn’t move too high up the complexity scale in a linear general-systems theory framework. Occupational therapists (in practice) tend to consider broader concepts of social and cultural context as they impact the individual. There are some noteworthy exceptions to this pattern – namely Reilly (1974) and to some extent Wilcock (1998) – but then again these referenced books had more to do with grand ideas and a little less to do with street-level occupational therapy.

Here is an example of how OT has traditionally considered contextual factors: Occupations, by their very nature, are interpreted within the context of personal meaning. Without this saturation of meaning, occupations are reduced to simple tasks that are foreign. Hasselkus (2000) describes her experiences of feeling stripped of her occupations when being immersed in an unfamiliar culture with unfamiliar routines. Deprived of her familiar context, she began to question her own identity. She expresses that her ability to participate in even simple but familiar routines provided a grounding foundation for her other experiences. Contextual relevance imbues meaning into occupation and occupation-centered practice requires the consideration of context. Occupational therapists consider contextual relevance by adopting narrative-based approaches in addition to or in substitution for performance component/bottom-up intervention approaches. Occupational history, occupational storytelling, contextual observations, and service provision in naturalistic settings all provide opportunities for collecting data regarding contextual factors.

This makes me wonder – is there a model for operationalizing the grand ideas of Wilcock and Reilly? I have been recently spurred into this question by reading Guns, germs and steel: The fates of human societies (Diamond, 1997). You can also find a nice website here that apparently corresponds to a PBS series that I have not yet seen. Diamond’s argument is that historical context as shaped by geographic factors is useful for understanding the shaping of societies. If his argument has merit, it should be able to be twisted down to looking at how historical and geographic context impacts the shaping of an individual.

Interestingly, Blanche & Henny-Kohler (2000) started looking at issues of cultural geography directly as they relate to occupational therapy knowledge – but their work just begins to scratch the surface of this very large question. Even though the initial question is not answered, the follow-up question is “To what degree is knowledge of these contextual factors helpful in street-level occupational therapy practice?”

I know that this discussion can degrade into a debate of basic vs. applied inquiry – and I am really not convinced that the profession or the scientists have really gotten the issue straight yet. Specifically, why are most undergraduate degrees in occupational science and the graduate degrees in occupational therapy? Does anyone else beside me see that this may be turned on its head?

Anyway, I encourage people to think about these issues – and Diamond’s book will take your brain to some interesting places regarding broad historical context. Does it matter to the people in the street? Let me know what you think… and happy reading!

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Captain of the U.S.S. ABC Therapeutics - private practice near Buffalo, NY. Part time educator and full time stirrer of pots, happily responding to people's needs from deep within the "darkness of free enterprise."